Have we reached a dead-end for diabetes care in low income settings?

I was recently asked by a friend of mine about the latest innovation in diabetes and could not find an answer. He challenged me saying after so many years working in diabetes that there must be something new and exciting in the world of diabetes, still no response from me. After much insistence I told him that in my opinion there were no real innovations in diabetes recently and that all new developments in the areas of medicines and technologies were not adding much to the life of people with diabetes.

He seemed puzzled. What about insulin pumps, new insulin analogues? Blood glucose meters and apps? Surely new medicines for the management of Type 2 diabetes were innovations?

I said I did not think so and that these were nothing new that truly changed the management of diabetes. He looked at me with a mix of incomprehension and almost anger. As he is medically qualified I asked him what the basics of good diabetes management. He mentioned diet, lifestyle, medicines and education. My next question to him was if this applied to all settings. He said of course yes, seemingly getting more and more upset with me.

Diet and lifestyle

To avoid losing a dear friend I then said I would now answer his question. My answer started with diet and lifestyle and explaining what he already knew about prevention and good diabetes management with these two factors. Knowing that he knew all of this I challenged him how many people do you think follow this guidance in a country like Switzerland (where I live and where we were having this discussion). He said very few. I asked why this happened although we knew what to do in terms of diet and lifestyle and our discussion on this topic included people’s lack of true understanding of lifestyle issues, healthcare workers not having enough time to explain or not explaining properly, the challenges of daily life, socio-economic factors, etc.

Surely, though, new medicines could be seen as an innovation or at least insulin delivery devices such as pens and pumps. I agreed that these were innovations, but asked him if innovations shouldn’t truly revolutionise the way “business as usual is done”. Of course he said, but don’t these do just that? Pens make injections easier, pumps allow for closer control of blood glucose. No argument against that, but people in many developing countries cannot access insulin or oral treatments for diabetes, let alone these fancy gadgets.

Challenging him I asked: “What would you do if he had to manage a 50 year old woman, with little education and possibly poor literacy and numeracy skills who needed to pay about 25% of her family income for her diabetes treatment and who needed to travel 1 hour to get decent diabetes care. When she got to the health centre she needed to wait anywhere from 2-3 hours for a 5 minute consultation and maybe if the reagents were there a blood glucose test.”

Even if she received information on how to manage the lifestyle factors of her diabetes that these were not realistic for her. The role of being a woman meant that exercising outside was impossible even if she wanted to in the 30 degree Celsius plus temperature. In addition her place in the social hierarchy meant that she had little say with regards to food consumed at home. If you find a way to address this case, I told him, that will truly be an innovation!

The reason for sharing this discussion with the GACD community is that the call for diabetes research by the GACD is very timely. We all know of the statistics about the rising burden and costs of diabetes. To a certain extent we also know what needs to be done, but we are faced with a knowledge-action gap. How do we take the knowledge we have about how to address diabetes and make this a reality for the most vulnerable populations and make the response adapted to their situation and needs not only to prevent diabetes and diabetes related complications, but also to improve their overall quality of life.

Publications

Non-communicable diseases in Mozambique: risk factors, burden, response and outcomes to date. Silva-Matos C, Beran D. Global Health. 2012 Nov 21;8:37. doi: 10.1186/1744-8603-8-37. Diabetes in Kyrgyzstan: changes between 2002 and 2009. Beran D, Abdraimova A, Akkazieva B, McKee M, Balabanova D, Yudkin JS. Int J Health Plann Manage. 2013 Apr-Jun;28(2):e121-37. doi: 10.1002/hpm.2145. Epub 2012 Nov 5. PMID: 23125073 [PubMed – in process] Related citations Select item 22939684 Delivering diabetes care in the Philippines and Vietnam: policy and practice issues. Beran D, Higuchi M.